In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the November 2025 Emergency Medicine Practice article, Diagnosis and Management of Emergency Department Patients With Alcohol Withdrawal Syndrome

  1. Epidemiology & Background
  • Rising ED visits related to alcohol use.
  • Mortality rates and spectrum of patient presentations.
  • Importance of high suspicion and complexity of cases.
  • Pathophysiology & Mechanisms
  • Alcohol metabolism and neurochemical changes.
  • Differential diagnosis: Conditions that mimic alcohol withdrawal.
  • Prehospital & EMS Considerations
  • Role of EMS in triage and initial management.
  • Use of sobering centers vs. ED transport.
  • Prehospital administration of benzodiazepines (IM midazolam).
  • History & Risk Assessment
  • Key questions to assess risk for alcohol withdrawal syndrome.
  • Importance of patient history, medication use, and comorbidities.
  • Discussion on patient honesty and rapport.
  • Physical Exam & Scoring Systems
  • DSM-5 criteria for alcohol withdrawal.
  • Use of CIWA-AR, BAWS, and PAWSS scoring systems.
  • Importance of objective measurement for monitoring and disposition.
  • Complications & Special Presentations
  • Complicated alcohol withdrawal: Hallucinosis, seizures, delirium tremens.
  • Diagnostic workup: Labs, imaging, and co-ingestions.
  • Special populations: End-stage liver disease, pregnancy, intubated patients.
  • Treatment Strategies
  • Mainstay: Benzodiazepines (types, dosing, and protocols).
  • Phenobarbital: Indications, dosing, and evidence.
  • Adjunctive therapies: Thiamine, glucose, magnesium.
  • Alternative/adjunct medications: Gabapentin, ketamine, dexmedetomidine, baclofen.
  • Clinical Pearls & Practice Changes
  • Early, aggressive therapy to prevent complications.
  • Symptom-based vs. fixed-schedule treatment.
  • Gabapentin as an alternative or adjunct.
  • Anti-craving medications for relapse prevention.
  • Disposition & Protocols
  • Use of scoring systems for safe discharge, observation, or admission.
  • Importance of protocolized approaches and community resources.
  • Summary & Take-Home Points
  • Five key practice-changing points.
  • Clinical pathway.

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